某區域醫院附設護理之家嚴重特殊傳染性肺炎群聚感染事件調查與應變處置經驗分享

Investigation and Response to a COVID-19 Outbreak in a Nursing Home Affiliated with a Regional Hospital

新型冠狀病毒（SARS-CoV-2）自2019年起造成全球人類的大量感染，2021年及2022年的5月至8月台灣出現嚴重的本土疫情，在歷經2年嚴格的防疫政策及醫護人員的努力後，疫情趨緩，於2023年5月衛福部疾管署正式宣布防疫降階，進入所謂的後疫情時代。但是在2024年6月，某區域醫院附設護理之家出現群聚感染事件，經過擴大匡列、篩檢及隔離等感染管制措施後，此群聚感染事件於7月結束，總共歷時22天。此次共有14位住民及4位工作人員染疫。依調查及實地觀察後推測造成傳播的可能原因為：1.未落實訪客及工作人員的健康管理；2.工作人員對住民健康狀況敏感度降低；3.工作人員未落實手部衛生及口罩配戴；4.未落實環境清消及動線管制。雖然COVID-19已降級解封，但仍有其他如流感等呼吸道傳染病傳播風險，希望藉此事件之經驗，作為其他長照機構於後疫情時代因應群聚感染事件之處置參考。

Since its emergence in 2019, the SARS-CoV-2 has caused widespread global infections. Taiwan experienced significant domestic outbreaks between May 2021 and August 2022. Following two years of stringent public health measures and the dedicated efforts of healthcare professionals, the situation stabilized. In May 2023, Taiwan’s Centers for Disease Control officially downgraded the national alert level after SARS-CoV-2 pandemic. However, in June 2024, a COVID-19 cluster outbreak occurred in a nursing home affiliated with a regional hospital. Through expanded contact tracing, screening, and isolation protocols; the outbreak was contained within 22 days. A total of 14 residents and 4 staff members were infected. The contributing factors to this cluster included: (1) inadequate health screening of visitors, (2) reduced vigilance among staff regarding personal health status, (3) lapses in hand hygiene and mask compliance, and (4) insufficient environmental disinfection and traffic flow control. Despite the downgrading of SARS-CoV-2 as a public health threat, this case highlights the continued vulnerability of long-term care facilities and provides important insights for infection control strategies in the post-pandemic context.